Monday, July 14, 2008

Medicine and Morality 2

It looks like the ministry of health is willing to study the option of "legalising organ trading in Singapore" after all.However, it seems that morality is still a consideration for the health minister when he said:"If you allow trading, currently those who volunteer for the family members or under HOTA, they may then object and say, 'since you can now buy organs, then why should I volunteer to save my family members?'Why should they indeed? After all, the aim of the transplant is to improve the patient's health, and not to give his relatives a chance to demonstrate their selflessness.While the chances of finding a matching donor amongst relatives are higher, with the proper selection process and follow-up, transplants from living unrelated donor (whether a spouse or a 'seller') have good long-term results. Patients whose relatives are unable or unwilling to donate their kidneys must look to unrelated donors, living or dead.More resistant to the idea, however, is the Singapore Medical Association:SMA against legalising human organ tradeBy Valarie Tan, Channel NewsAsiaSINGAPORE: Doctors in Singapore are split over whether human organ trading should be legalised in the country. A medical ethics debate over the issue has been re-ignited in recent weeks after five persons were prosecuted over illegal kidney-for-sale deals.For the Singapore Medical Association (SMA), after much internal discussion, it has come to a collective stand that it does not support legalised organ trading.In response to queries by Channel NewsAsia, the SMA said that besides the medical risks to the organ seller, there is too much potential for abuse of disadvantaged individuals. It is also difficult to make the process transparent and equitable.The SMA represents two-thirds of doctors and specialists from the private and public hospitals in Singapore. It said emails and discussions were exchanged over the past two weeks, and its 16-member council held an emergency meeting on Saturday to deliberate.Dr Tan Sze Wee, a spokesperson for the SMA, said: "Within the council itself, we had a debate and the views were split down the middle as well, between those who felt that there could be a possibility of legalising it because of the good it can bring to the recipients - the quality of life, saving a life."However, the other point that we still felt was very important is - how are you able to administer it? The devil is in the details."But with the number of kidney patients growing in Singapore, the SMA said the call to legalise organ trade may grow stronger in the future.Dr Tan said: "It may, but the voice for legalising organ trade is not something that's a current topic. It has been around since the beginning of time. But we recognise the fact that the human body itself cannot be treated like a commercial property that it can be traded with a value."There are medical complications, short-term and long-term. The short-term risks are... the operation itself, anaesthesia for both the recipient and the donor in the surgery."Long-term risks are: if you have two kidneys and you donated one... what do you do when something happens to you? Some accident or some illness, then you've got no back-up plan. And, it's well documented that organ donors do suffer from, what we call, donor remorse."The SMA was not able to comment on the implications on the growing number of patients getting transplants from non-related donors in Singapore. In 2007, 33 patients received kidneys from non-related living donors compared to 19 in 2006 and six in 2005.However, the SMA does support the suggestion to have transplant patients screened at the Health Ministry level, instead of just leaving it to a hospital ethics committee.Dr Tan said: "I think that's definitely better. I think that is something for the ministry to work out to ensure that such cases do not repeat again."There are so many things that can possibly happen that even if you want to think about ways to put safeguards in to prevent illegal activities from happening, there are a lot of details that have to be worked out."(snip)angry doc wonders how the SMA, with it's membership "split down the middle", could choose to make a stand on the issue; essentially, SMA is making the stand of one-third of doctors in Singapore its official stand.What is worse are the reasons SMA had given for opposing the legalisation of organ trading.Had the SMA stuck to the moral argument of "the human body itself cannot be treated like a commercial property that it can be traded with a value", angry doc would have respected that, even if he did not agree with it.However, Dr Tan showed that the SMA's position may stem more from a lack of moral courage than moral conviction when he argued:"There are so many things that can possibly happen that even if you want to think about ways to put safeguards in to prevent illegal activities from happening, there are a lot of details that have to be worked out," and when he asked "how are you able to administer it? The devil is in the details.".In other word, faced with the complexity of the task of regulating organ trading, SMA has chosen to object to it than to participate in looking at whether we can create a system that will minimise unfairness to parties concerned. How noble.Dr Tan also could not help throwing in some flawed arguments against organ trading:

"There are medical complications... The short-term risks are... the operation itself, anaesthesia for both the recipient and the donor in the surgery."

This is not a valid argument because all surgeries which are performed under anaesthesia carry anaesthetic risks. More importantly, risks to donor and recipient are similar whether they are related or unrelated. If the SMA's position is (as angry doc's is) that it is unethical to subject a person (the donor) to anaesthetic risks for a surgery that does not benefit him physically, then should it not similarly object to living-related transplant?

"...if you have two kidneys and you donated one... what do you do when something happens to you? Some accident or some illness, then you've got no back-up plan."

Here Dr Tan chose to appeal to fear, instead of providing the public with actual risks to donors in the form of statistics to allow them to make their own decisions on whether or not donation constitutes an unacceptable risk.How many donors actually require renal replacement therapy due to trauma to their single remianing kidneys? How many donors go into chronic renal failure due to diseases which would not have affected both kidneys equally had he not donated one anyway?If Dr Tan is concerned with the lack of a "back-up plan" for donors, will it not be better to provide for their interests by having a regulated system that covers their medical follow-up and costs, and which makes more organs available?angry doc feels that Dr Tan had not represented the position of the half of its membership which do not oppose legalisation of organ trading adequately or fairly; by making a moral stand on the issue and backing it up with flawed arguments, Dr Tan gives the impression that the SMA is willing to impose the morality of some doctors over the public, and that its members either think that the public are too dumb to see through the flawed arguments, or that its members themselves are, when in reality it may be more a case of SMA being unwilling to tackle the issues of organ trading head-on.The fast pace of progress in medical science means that we are now often faced with treatment options which are not available a generation ago - options which morality we, as a society, have yet to come to an agreement on. angry doc feels that while doctors are individually entitled to their own moral viewpoints, and as a profession our ethics allow us to choose whether to participate or refrain from participation in a certain type of treatment, as advocates for our patients our role when it comes to a medical issue should be one of active participation through education and provision of information. We must not try to abdicate our responsibilty while using the morality of a portion of doctors as an excuse.

11 Comments:

Thanks for the information on organ trading. Those are some good ethical issues.

We recently wrote an article on at Brain Blogger. When treating patients, a lot of doctors qualify their patients as "good" and "bad". Sometimes, a doctor may pass on a "bad" patient to another doctor, saying that the patient is "beyond the scope of his practice." Though sometimes there is a good reason behind this, is it ethically right to pass on an annoying patient to another doctor?

SMA council members have a discussion among themselves and it is supposed to be representative of all their members' views?

They didn't poll any of us. I'm a SMA member.

I personally support legalized organ sale.

Here are some suggestions of what kind of regulations I would introduce:

1) A fixed price for the kidney marked as a X% of the recipient's annual income.

2) All donors keen to sell their kidneys register with MOH and have their samples taken and banked.

3) All recipients willing to buy a kidney will deposit X% of their annual income with MOH as a holding authority.

3) Donors are not allowed to choose who they sell their kidneys to. In the case of a successful match, the donor will be told that their is a suitable recipient and he will get the X% if the recipient's annual income (without letting him know how much that is)

4) If agreed, the procedure takes place and the money will be credited to the donor's account from MOH's holding authority.

I think this is rather simple and of course a discussion can be made on this to improve or find loopholes etc.

However I think this system is fair as it would not really invite a slew of people selling their kidneys. The "unknown" factor as to how much you are going to get is pretty much like a lottery so it encourages people to really think of "donation" first and compensation as secondary.

If one is lucky and donates to Tang Wee Sung, then good for him. But there might be another donor who donates to someone who is a low income earner with 5 kids and although the $$$ is little he has the satisfaction of seeing the father going back to work and supporting his family.

"SMA council members have a discussion among themselves and it is supposed to be representative of all their members' views?"

They received emails on the subject, but how many was not stated in the report.

I think the process for 'blind' donation can probably be copied from bone marrow donation programmes.

As for payment/compensation, I am more inclined to propose a fixed price than a "lottery". We should be upfront about how much a donor will get so there is no last-minute withdrawal when the donor finds the price not up to his expectations.

The price may be pegged to the cost of dialysis for X number of years, revised each year.

Payment may be made in a lump sum, or credited monthly as appropriate.

To make it affordable, the programme can be subsidised by the government with means-testing, or by charity (similarly with means-testing).

I think no matter how we design it, the system will still 'exploit' the poor; but we can design it such that the poor can also benefit from it.

Having a fixed price might price out poorer patients from having a transplant.

It also makes sense that the richer should pay more and the poorer pay less (although fixing it at a % of their annual income would be fairest).

Going back to my suggestion of the lottery system. Why worry about last minute withdrawals? The system I suggested is such that the primary aim is that the donor donates (not so much get money). Money is only credited after the donation is done and it would be transparent after that (ie the recipients tax assessment etc will be revealed to justify how much was paid etc)

The purpose of my suggestion is to allow for legalized organ trading in fair terms with the basic premise of "donation" being the focus rather than on "profits".

How successful in terms of the increased numbers of donors I am not too sure. But it definitely would prevent a lot of the feared abuse situations at the same time satisfying the part of society that is lobbying for organ sales.

Think of it as a hybrid fusion between organ sales and organ donation.

Perhaps we can look at it as the FIRST STEP forward without causing too big of a change from the present donation system.

You see when it comes to pricing it is a HUGE headache. In fact that is the biggest headache I think will stall any plan. What price is right?

A price that is cheap to a multi millionaire will be criticized as being too cheap or unfair to the donor. A price too expensive will be unfair to the poorer recipients.

Pegging the price to the person's ability to pay however becomes more fair to the recipient and also the donor should understand bearing in mind the MAIN point should be organ DONATION not the money.

As for the lottery system (actually dun call it lottery lah makes it sound so money minded, people want to donate and be compensated somewhat mah).....yes it is true that we do not know whether it will encourage or discourage donors. However it will be an available option and at least keep the pro-organ trade camp quiet for a while.

In this country, government subsidy has led to a system where basic healthcare is affordable and accessible to most, and subsidy by charity has led to many poor people receiving treatment which they would not otherwise have been able to afford, as well as two CEOs of charities being charged in court. :)

"What price is right?

A price that is cheap to a multi millionaire will be criticized as being too cheap or unfair to the donor. A price too expensive will be unfair to the poorer recipients."

Which is why I proposed means testing.

Let's look at some figures.

We can look at the "actual" cost of a graft in terms of the "cost saved" to the recipient in terms of dialysis costs. At the current market rate and assuming an average graft survival of 10 years, we are looking at S$300,000. (Gee, why does that figure sound familiar?)

For someone with low income (of say S$1500 per month), this is equivalent to 16 years of pay. (Gee, why does that figure sound familiar?)

It will cost S$180 million to buy kidneys for all 600 or so patients currently on our waiting list.

Each year about 600 new patients will end up with renal failure. Although not all with be eligible for transplant, we should be looking at a market of more or less S$180 million a year.

The cost to the recipient will be the cost of the graft plus surgery, which brings the total to about S$360,000. Presumably not too many of the 600 or so patients on the waiting list will consider that small change, so we may not have to worry about being easy on the rich.

At a standard 80% subsidy for "C class" patients, the cost is around S$72,000, still hefty for most people, so we will need either a heavier subsidy rate or help from a charity.

"actually dun call it lottery lah"

The system being how it is, people will most certainly call it a lottery system. :)

I understand the argument behind your proposal, but I am not sure it will please any party. Still, we need all the ideas and opinions we can get. Parliament will be discussing the issue, so you may want to email Halimah Yacob about this scheme.

INTRODUCTION: Living donor liver transplantation (LDLT) has progressed dramatically in Asia due to the scarcity of cadaver donors and is increasingly performed in Singapore. The authors present their experience with adult LDLT. MATERIALS AND METHODS: Adult LDLTs performed at the Asian Centre for Liver Diseases and Transplantation, Singapore from 20 April 2002 until 20 March 2006 were reviewed. All patients received right lobe grafts and were managed by the same team throughout this period. Data were obtained by chart review. This study presents both recipient and donor outcomes in a single centre. RESULTS: A total of 65 patients underwent LDLT. Forty-three were genetically related while 22 were from emotionally-related donors. success rate. The mean follow-up (snipped)There was 1 donor mortality and morbidity rate was 17%. Our series is in its early stage with good perioperative survival outcome with 1-month and 3-month actuarial survival rates of 95.4% and 87.3% respectively.